Differential Diagnosis

The patient presents with severe pain and swelling in the right ankle, low-grade fever, recurrent pedal edema, insomnia, and frequent voiding episodes. The laboratory results and physical examination findings suggest a complex clinical picture. Here is a differential diagnosis organized into categories:

• Single Most Likely Diagnosis
  • Gouty Arthritis with Chronic Kidney Disease (CKD): The patient's history of recurrent ankle swelling, relief with Diclofenac, and presence of hyperuricemia (suggested by the urinalysis results) support gout. The elevated creatinine and BUN levels, along with the presence of parenchymal disease on the KUB ultrasound, indicate CKD. The patient's hypertension, use of diuretics (HCTZ), and hyperuricemia are risk factors for CKD.
• Other Likely Diagnoses
  • Septic Arthritis: The patient's symptoms of severe pain, swelling, erythema, and warmth in the right ankle, along with a low-grade fever, could suggest septic arthritis. However, the absence of a clear history of trauma or recent infection makes this less likely.
  • Pseudogout (Calcium Pyrophosphate Deposition Disease): This condition can cause similar symptoms to gout and is also associated with kidney disease.
  • Hypertensive Nephrosclerosis: The patient's long-standing hypertension could have led to kidney damage, contributing to the CKD.
• Do Not Miss Diagnoses
  • Infective Endocarditis: Although less likely, the patient's symptoms of fever, insomnia, and frequent voiding episodes, along with the presence of cardiomegaly on the chest X-ray, could suggest infective endocarditis. This diagnosis would be deadly if missed.
  • Kidney Stones: The patient's symptoms of frequent voiding episodes and the presence of hematuria (RBC 10-20) on urinalysis could suggest kidney stones.
• Rare Diagnoses
  • Amyloidosis: This condition can cause kidney disease, cardiomegaly, and joint symptoms, but it is relatively rare and would require further testing to confirm.
  • Multiple Myeloma: The patient's anemia (Hgb 100), kidney disease, and hypercalcemia (suggested by the elevated phosphate level) could suggest multiple myeloma, but this diagnosis is less likely and would require further testing to confirm.